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    Neonatal Sepsis Notes

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    Neonatal Sepsis Notes

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    Neonatal Sepsis Notes

    Uploaded by

    jmugi22

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    Major Complications

    of the newborn
    DEFINITION
    Neonatal sepsis (NS) is defined as clinical
    syndrome of bacteremia with systemic signs
    and symptoms of infection in the first four
    weeks of life.
    ETIOLOGY
    Common organisms identified:
    1. Escherichia coli.
    2. Group B Streptococci.
    3. Coagulase negative staphylococci.
    4. Streptococcus pneumoniae.
    5. Listeria monocytogenes.
    6. Klebsiella pneumoniae.
    7. Acinetobacter species.
    8. Pseudomonas aeruginosa.
    9. Candida.
    EPIDEMIOLOGY
    Incidence:
     1-8 cases per 1,000 live births.
    Mortality:
     13-70% world wide.
     13-15% of all neonatal deaths (USA) (8th cause).
    Morbidity:
     Meningitis occurs in one third of sepsis cases.
    Sex:
     Males > Females (2 - 6 times).
    Age: premature infants
     Weight 1,000-2,000 gm: 8-9/1,000.
     Weight <1,000 gm: 26/1,000).
    EARLY ONSET
    NEONATAL SEPSIS (EONS)
    • Infection occurring in the first 3 days of life.
    • 5-7/1,000 live births.

    Exposure can occur:


    1. Before delivery:
    • Infected amniotic fluid.
    • Untreated maternal sepsis.
    2. During delivery:
    • Organisms in maternal genital tract.
    3. After delivery:
    • Exposure to external organisms.
    4. Environment:
    • Suction tubes; ambubags, resuscitoire, O2 masks…
    Risk factors:

    1. Premature rupture of membranes


    (PROM).
    2. Infection in the mother.
    3. Presence of group B Streptococci
    (GBS) in the mother.
    Pathophysiology

    1. The infant has acquired the organism during the intra-


    partum period from the maternal genital tract.
    2. Could be acquired trans-placentally.
    3. With rupture of membranes, vaginal flora or various
    bacterial pathogens may ascend to reach the amniotic
    fluid and the fetus → Chorioamnionitis → fetal
    colonization and infection.
    PRIMARY SITES of colonization:
    1. Nasopharynx.
    2. Oropharynx.
    3. Conjunctiva.
    4. Umbilical cord.

    Aspiration of infected amniotic fluid by the fetus or


    neonate may play a role in resultant respiratory
    symptoms.
    • Early onset NS manifests as:
    1. Pneumonia (Frequently)
    2. Less commonly as:
    • Septicemia.
    • Meningitis.
    The associated factors for EOS

     Low birth weight.


     Prolonged rupture of membranes > 24 hours.
     Foul smelling liquor.
     Multiple PV examinations.
     Maternal fever.
     Difficult or prolonged labour.
     Aspiration of meconium.
    LATE ONSET NEONATAL SEPSIS
    • Occurs 4 – 7 days after birth.
    • Usually due to organisms thriving in the
    external environment.
    • Presents with:
    1.Septicemia.
    2.Pneumonia.
    3.Meningitis.
    1. Lack of hand hygiene by health care givers.
    2. Low birth weight.
    3. Lack of initiating breast feeding.
    4. Skin infections.
    5. Aspiration of feeds.
    6. Disruption of skin integrity with needle pricks and/or
    use of IV fluids.

    • These enhance the chances of infection in the


    neonates (who have an already poor immune
    defense mechanism).
    Early vs Late Onset NS
    Early Onset NS Late Onset NS
    Onset <72 hrs >72 hrs
    Source Maternal genital tract Environmental (nosocomial)

    Risk factor Prematurity, Amnionitis, Prematurity


    Maternal infection

    Presentation Fulminant Slowly progressive


    Pneumonia frequent Septicemia & Meningitis
    frequent

    Mortality 5-50% 10-15%


    • Manifestations of neonatal sepsis are usually
    VAGUE and demand A HIGH INDEX OF
    SUSPICION for early diagnosis.
    Most common manifestations include:
    1. Respiratory distress in early onset NS.
    2. Altered feeding behavior in a well established feeding
    newborn (aspiration, vomiting, etc).
    3. Baby who was active, suddenly or gradually becomes
    lethargic, inactive or unresponsive and refuses to suckle.
    4. Temperature instability: Hypo- or hyperthermia.
    5. Skin: Poor peripheral perfusion, cyanosis, pallor,
    petechiae, rashes, or jaundice.
    6. Metabolic: Hypo- or hyperglycemia or metabolic
    acidosis.
    Signs of severe sepsis
    • Episodes of apnea or gasping breaths in a baby who was
    otherwise stable.
    • Diarrhea, vomiting and abdominal distension.
    • Cyanosis.
    • Shock.
    • Others:
    – Prolonged capillary refill time > 3 seconds.
    – Bleeding.
    – Renal failure.
    A. Non-specific:

    • White blood cell count and differential:


    – Neutropenia can be a threatening sign (< 1,800/cmm).
    – Immature to Total neutrophil (I:T) ratio ≥ 0.2 is predictive
    (Normal: ˂ 0.16).
    • Acute phase reactants:
    – C-Reactive Protein (CRP): rises early.
    – ESR rises > 15 mm 1st hr.
    • Platelet count:
    – Decreases, a late sign and non-specific.
    • Others:
    – Bilirubin, glucose, sodium.
    B. Definitive, specific:
    • Cultures:
    – Blood:
    • Confirms sepsis.
    – Urine:
    • Don’t need in infants <24 hours old because UTIs are
    exceedingly rare in this age group.
    – CSF:
    • Controversial ????
    • May be useful in clinically ill newborns or those with
    positive blood cultures.
    Radiology
    1. Chest X-Ray:
    – For infants with respiratory symptoms.
    2. Renal ultrasound:
    – For infants with accompanying UTI.
    3. CT scan:
    – For infants with probable meningitis or seizures.
    Differential Diagnosis

    1. Respiratory distress syndrome (RDS).


    2. Metabolic diseases.
    3. Hematologic diseases.
    4. CNS diseases.
    5. Cardiac diseases.
    6. Other infections (e.g. ToRCH infections).
    1. Antibiotics:
    a. Primary sepsis: ampicillin and gentamicin.
    b. Nosocomial sepsis: vancomycin and gentamicin.
    c. Cefotaxime, if meningitis is suspected.

    Should be based on culture & sensitivity


    2. Supportive therapy

    • Respiratory:
    • Oxygen and ventilation as necessary.
    • Cardiovascular:
    • Support blood pressure with volume expanders.
    • Hematologic:
    • Treat DIC.
    • CNS:
    • Treat seizures with phenobarbital.
    • Metabolic:
    • Correct hypo-/hyperglycemia and metabolic acidosis.
    PREVENTION OF NEONATAL SEPSIS
    1. Good antenatal care.
    2. Maternal infections diagnosed and treated early.
    3. Babies should be breastfed early.
    4. Infection control policies applied in the unit.
    GENERAL PRINCIPLES
    1. MINIMIZE.
     Handling of neonates.
     Invasive procedures.
     Visitors.

    2. Staff should perform hand washing:


     Upon entering and leaving the nursery.
     Between infants.

    3. Equipment should not be shared between infants.


    4. Practice aseptic techniques.
    SKIN CARE
    • Cord should be cleaned/dried.
    • Daily washing has no value in
    infection control.
    • The only time whole body bathing
    and antiseptic soaps are indicated is
    during an infection outbreak.
    • Soiled areas showed be gently
    cleaned, avoid damage to the skin.
    • Adhesive tapes that damage
    neonate’s skin should be avoided.

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